Having a stroke in the hospital can mean slower care, not faster

Some of the sickest patients with the most urgent need for stroke treatment may be the least likely to receive timely life-saving care because they're in the hospital when the stroke hits, according to a new study.

Compared with stroke sufferers whose symptoms began outside of a hospital, hospitalized patients waited more than two hours longer for brain scans. They were also “more likely to be dead or disabled at discharge,” according to a study published Monday in the journal JAMA Neurology.

Dr. Douglas Dulli, of the University of Wisconsin's neurology department, called the results striking and paradoxical in an accompanying editorial. Yet virtually all similar studies over the last 15 years have come to comparable conclusions, he noted.

There are also implications beyond stroke care, such as for patient falls and other preventable events, said American Stroke Association spokesman Dr. Lee Schwamm. Ironically, the push for private, hotel-like hospital rooms to improve the patient experience may have reduced the ability to provide the frequent surveillance needed to promptly detect a change in a patient.

In the latest study, Canadian researchers used data from the Ontario Stroke Registry to look at patients who presented to 11 regional stroke centers between July 2003 and March 2012. They compared outcomes for 973 patients who were already in the hospital at the onset of a stroke with 28,837 individuals whose symptoms began in a community setting.

While patients in the hospital waited 4.5 hours from the time their symptoms were recognized to the time they underwent brain imaging, patients whose strokes began outside of the hospital waited about 1.2 hours.

Hospitalized patients were also about 5% less likely to receive thrombolysis, a treatment that works to rapidly dissolve blood clots, restart blood flow to the heart and prevent damage to the heart muscle. When the patients did receive the treatment, they waited nearly an hour longer for it than those who had to be transported to a hospital.

The study authors noted several limitations to the study. For example, already hospitalized patients tended to be older, generally had more severe strokes and were more likely to have serious medical conditions such as heart failure or diabetes.

“It means that even with optimal care, these patients are less likely to do well after stroke and they may not be eligible for certain treatments,” explained researcher Dr. Moira Kapral of Toronto's Institute for Clinical Evaluative Sciences, in a JAMA Neurology podcast.

When researchers adjusted for age, stroke severity and other factors, they found patients suffering strokes in hospitals stayed on average nine days longer in the hospital after the episode and their likelihood of dying or being disabled increased by 12%.

The data sources did not contain information about the reasons for delays in diagnosis or treatment among already hospitalized patients. It is also unclear whether the patients ultimately died as a result of the stroke or from the condition for which they were admitted.

In-hospital strokes happen far less frequently, which makes them more difficult to address. Dulli co-authored a 2007 study looking at the problem in the U.S. That study estimated in-hospital strokes could represent between 4% and 17% of all acute strokes.

Despite the small numbers, experts say the findings highlight a lack of full understanding about the risks faced by this population of patients. They recommend a standardized approach to the recognition and management of patients that experience strokes while in hospital care.

A more prescriptive clinical protocol could reduce the striking paradox in which care is limited or delayed in the very setting where state-of-the-art stroke therapy is “only an elevator ride away,” Dulli said.

There is also a need for investing in staff and technology to provide continuous, high-frequency observations, especially as more hospitals adapt private or semi-private patient rooms, advised Schwamm, vice chairman of neurology at Massachusetts General Hospital, Boston. Patients often go for hours between visits from clinical staff, and there is no opportunity for a suite mate to alert staff to an issue in private patient rooms.

“The reality is that a hospital is kind of a lonely place,” Schwamm said. “And that can potentially lead to some negative health consequences."